Pediatric Associates of Canon City, Prof. LLC

Primary specialty

Pediatric Adolescent Medicine PhysicianTaxonomy code 2080A0000X

License

23117 Issued in CO

Legal business name

PEDIATRIC ASSOCIATES OF CANON CITY, PROF. LLC

Practice address

1335 Phay Ave
Suite a
Canon City, CO 81212-2334

Phone

(719) 269-1727

Fax

(719) 269-1730

NPI assigned

Jan 31, 2007

Last updated

Aug 22, 2020By the provider in NPPES

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Mr. Roger Deane Noland

Title

General Manager

Phone

(719) 269-1727

Specialties & licenses 1

Addresses

Other identifiers 2

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1170201600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1598054400000",
    "number": "1457498131",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "1335 PHAY AVE",
            "address_2": "SUITE A",
            "city": "CANON CITY",
            "state": "CO",
            "postal_code": "812122334",
            "telephone_number": "719-269-1727",
            "fax_number": "719-269-1730"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1335 PHAY AVE",
            "address_2": "SUITE A",
            "city": "CANON CITY",
            "state": "CO",
            "postal_code": "812122334",
            "telephone_number": "719-269-1727",
            "fax_number": "719-269-1730"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "PEDIATRIC ASSOCIATES OF CANON CITY, PROF. LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2007-01-31",
        "last_updated": "2020-08-22",
        "status": "A",
        "authorized_official_last_name": "NOLAND",
        "authorized_official_first_name": "ROGER",
        "authorized_official_middle_name": "DEANE",
        "authorized_official_title_or_position": "GENERAL MANAGER",
        "authorized_official_telephone_number": "719-269-1727",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "2080A0000X",
            "taxonomy_group": "",
            "desc": "Pediatrics, Adolescent Medicine",
            "state": "CO",
            "license": "23117",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "05638655",
            "state": "CO"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "01271139",
            "state": "CO"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Marion M Patterson, RN
• Anna Kristin Payne, RDN
• Peak Vision Canon City Prof, LLC
• Basil Eugene Pearson, D.C.
• Lisa G Pearson, DNAP, CRNA, NSPMC
• Raymond J Pelland, PA-C
• Jody L Pendleton, LPC
• Phyllis A Pennington, DO
• Paula M. Peterson, LMT, MSOM
• Carol J Pfaffly, PHD

• Pediatric Adolescent Medicine Physician in Canon City, CO
• Providers in Canon City, CO by specialty
• Pediatric Adolescent Medicine Physician in Colorado

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Aug 22, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.